Health Care

More Minorities Fall Into the Gap of Medicaid's Patchwork Expansion

Almost 5 million Americans will miss out on the expanded Medicaid coverage originally included in the Affordable Care Act, and new analysis of the excluded group found that it’s disproportionately black and Hispanic.

In the 25 states that have opted not to expand the state-run insurance program for low-income families, more than half of those who will fall into the coverage gap are minorities, according to a report by the Kaiser Family Foundation found. By Census data, however, minorities make up just more than one-third of the population in those states. Kaiser’s figures don’t count undocumented immigrants, who aren’t eligible for Medicaid.

Minorities are more likely to be uninsured than whites, and states expanding Medicaid in 2014 have a chance to narrow that disparity. The people left out of the Medicaid expansion, by Kaiser’s estimate in a related report, include 2.2 million whites, 1.3 million blacks, 1 million Hispanics, and 300,000 members of other minority groups. They’re all poor, making less than $16,000 for an individual or $32,000 for a family of four.

Texas is the largest state opting not to expand Medicaid after the Supreme Court ruled in 2012 that Obamacare couldn’t force states to widen eligibility for the program. Because of the decision, more than 1 million Texans won’t qualify for coverage. Three-quarters of those are nonwhites, according to Kaiser’s data, a greater share than in any other state. More than two-thirds are members of a working family.

Roughly one in five Americans under 65 has no health insurance, and the health-care reform law as passed by Congress almost four years ago used several mechanisms to expand coverage.

Medicaid, created in 1965 to provide health care for the poorest Americans, would be expanded to cover adults making as much as 138 percent of the poverty line, or about $16,000 a year—slightly more than what you’d make at the federal minimum wage if you worked 40 hours a week for 52 weeks. People earning more than that get subsidies to buy private health coverage in the insurance exchanges if they don’t already get affordable coverage through their jobs.

After the Supreme Court made the Medicaid expansion optional, about half the states skipped it, mostly states in the South and Great Plains. Many of the opt-out states are reliably red, and there’s a lot of overlap with the states that voted for Mitt Romney in the last election.

Most of these states already had strict requirements for getting Medicaid coverage. The median threshold for eligibility was just 47 percent of the poverty line, according to the Kaiser Foundation, meaning that a family of four would have to earn less than $11,000 a year to qualify. In many of the states, adults without children aren’t eligible for Medicaid no matter how little they make.

In states that are expanding Medicaid, the federal government will shoulder the full cost of the expansion for three years. Beyond that, states will have to contribute as much as 10 percent. Even some Republican governors who oppose Obamacare saw this as a good bargain for their states. “While the federal government is committed to paying 100 percent of the costs, I cannot deny Floridians who need access to health care,” Florida Governor Rick Scott said earlier this year, though state lawmakers nixed the idea. Other GOP governors had more success: John Kasich of Ohio, Rick Snyder of Michigan, and Chris Christie of New Jersey all went along with the Medicaid expansion.

States are about to diverge again in how their poor residents can access health care, magnifying America’s familiar racial disparities. As Kaiser reports:

“In states that do not expand Medicaid, millions of poor adults will be left without a new coverage option, particularly poor uninsured black adults residing in the South, where most states are not moving forward with the expansion. Four in ten uninsured Blacks with incomes low enough to qualify for the Medicaid expansion fall into the gap, compared to 24% of uninsured Hispanics and 29% of uninsured whites. These continued coverage gaps will likely lead to widening racial and ethnic as well as geographic disparities in coverage and access.”